Sepsis management

ABSTRACT

The present invention concerns methods for aiding in the risk assessment of a patient with suspected sepsis. For example, the risk of poor outcome (such as of a complicated clinical course and/or of mortality) can be assessed. The methods of the present invention may comprise the steps of (a) determining the amount of the biomarker Presepsin in a sample from a patient with suspected sepsis who has a known qSOFA (quick Sequential Organ Failure-Assessment) score of 0, 1, 2 or 3, (b) determining the amount of the biomarker Pro-calcitonin (PCT) in a sample from the patient, comparing the amounts determined in steps (b) and (c) to reference amounts, and (d) aiding in the risk assessment of a patient with suspected sepsis. The methods of the present invention may be computer-implemented.

The present invention concerns methods for aiding in the risk assessmentof a patient with suspected sepsis. For example, the risk for a pooroutcome (such as of a complicated clinical course and/or of mortality)can be assessed. The methods of the present invention may comprise thesteps of (a) determining the amount of the biomarker Presepsin in asample from a patient with suspected sepsis who has a known qSOFA (quickSequential Organ Failure-Assessment) score of 0, 1, 2 or 3, (b)determining the amount of the biomarker Procalcitonin (PCT) in a samplefrom the patient, comparing the amounts determined in steps (b) and (c)to reference amounts, and (d) aiding in the risk assessment of a patientwith suspected sepsis with regard to clinical outcome. The methods ofthe present invention may be computer-implemented.

During the initial presentation of a patient with suspected sepsis, forexample in the hospital emergency room, it is both challenging andprognostically crucial to rapidly and reliably distinguish between lowrisk patients with mild sepsis, good prognosis and low in-hospitalmortality rate and high risk patients with potentially life-threateningsepsis with need for intensive care and high mortality rates. Earlydiagnosis and adequate treatment are crucial for the prognosis ofpatients with sepsis. Patients with sepsis present very differently,which makes clinical assessment difficult. A Dutch study with sepsispatients revealed that 30-50% of the patients, sometimes even those inseptic shock, were considered to be ‘non-urgent’ (Eur J Emerg Med 2014;21(5):330-335. The lack of recognition of the life-threatening clinicalpicture delays significantly targeted therapy and is associated withincreased mortality.

However, in order for sepsis patients to be treated adequately, theyfirst must be identified and the correct diagnosis made. Sepsis isdefined in accordance with SEPSIS-3 (Sepsis-3 The Third InternationalConsensus Definitions for Sepsis and Septic Shock. JAMA 2016;315:801-819) as “a life-threatening organ dysfunction caused by adysregulated host response to infection” and is recommended to beassessed clinically with the Sequential Organ Failure Assessment (SOFA)score.

The use of the SOFA score is not deemed appropriate for the emergencyroom due to the complexity of the parameters considered. In order toremedy the situation, the authors of the SEPSIS-3 definition proposed tointroduce the quick SOFA (qSOFA) score to predict the likelihood oforgan dysfunction in patients with suspected sepsis. The qSOFA score isa three-point score with one point each for tachypnea, hypotension andaltered mentation. The “positive” qSOFA score with two or three pointsindicates risk for a worse clinical outcome. Due to its simplicity, theqSOFA score can be used in the emergency department and in non-intensiveareas to identify adult patients with suspected sepsis who are likely tohave poor outcomes.

Numerous studies have determined qSOFA to be superior to the previouslyused SIRS criteria both in terms of specificity and predictive accuracyof the expected mortality rate. In the case of a qSOFA score of ≥2points, a complicated clinical course or increased mortality is to beexpected. However, patients with a qSOFA score of <2 may already becritically ill, if not in need of intensive care, because at least oneincipient failure of the circulatory, respiratory or central nervoussystem is present. Sensitivity of the qSOFA at the time of hospitaladmission for the correct identification of patients who subsequentlydie from sepsis during their stay in hospital is only about 50-70%(Lancet Infect Dis 2017; 17:661-670; JAMA 2017; 317:301-308; Chest 2017;151(3):586-596).

In addition to clinical experience, targeted laboratory examinations toassess the course of the disease and patient's outcome may be helpful.Commonly used inflammatory markers (such as leukocyte count and CRP) areless sensitive or specific. The elevated PCT (Procalcitonin)concentration in the blood indicates the presence of a systemicbacterial infection. Furthermore, in numerous studies, Presepsin(sCD14ST) has been demonstrated to be a useful biomarker for assessingthe severity of sepsis (Critical Care 2014; 18:R6 and Critical Care2013; 17: R244).

The criticism of the new qSOFA score as a screening test, essentiallyrefers to the following points: 1.) Start of therapy may be delayed andtherefore cause the prognosis to worsen as the qSOFA score onlyrecognizes patients if they are already in need of intensive care. 2.)High specificity but at the expense of sensitivity. The qSOFAdemonstrated significantly lower sensitivity in all previously publishedprospective studies compared with the SIRS criteria (in favor of ahigher specificity) and a negative qSOFA score cannot rule out sepsis.3.) No biomarkers other than lactate as point-of-care bedside test havebeen integrated into SEPSIS-3, although various biomarkers fordiagnosis, prognosis, and therapy have been used internationally formany years in routine care, on the basis of numerous studies.

There is a clear longstanding need for means and methods for aiding inthe quick and reliable assessment of patients with suspected sepsis toadequately predict outcome and for making appropriate therapeuticdecision for such patients.

Thus, the technical problem underlying the present invention must beseen as the provision of means and methods for complying with theaforementioned needs. The means and methods shall, at the same time,avoid the drawbacks of the prior art referred to above.

The technical problem is solved by the embodiments characterized in theclaims and herein below.

Advantageously, it has been found in the studies underlying the presentinvention that patients with a suspected sepsis, the combination ofquick SOFA scores and the determination of both Procalcitonin andPresepsin in the blood improves the detection of a potentiallycomplicated clinical course and the assessment of the mortality risk.The predictive validity of the qSOFA scores is significantly improvedwith the addition of both Procalcitonin and Presepsin. In particular,the combined determination of Procalcitonin and Presepsin allows for theidentification of risk patients, who—based on the qSOFA alone—would havenot been considered to be at risk (such as patients with a qSOFA scoreof 0 or 1). Further, the combined determination of Procalcitonin andPresepsin allows for the identification of patients whose risk for apoor outcome—based on the qSOFA score alone—would have beenoverestimated (such as patients with a qSOFA score of 2 or 3). Thanks tothe findings of the present invention, it will be possible to make quickand reliable decisions in patients with suspected sepsis who needescalated care to prevent deterioration, such as in patients presentingat an emergency department with suspected sepsis.

Accordingly, the present invention relates to a method for aiding in therisk assessment, such as the prediction of the outcome, of a patientwith suspected sepsis, comprising

-   -   (a) determining the amount of the biomarker Presepsin in a        sample from a patient with suspected sepsis who has a known        qSOFA score of 0, 1, 2 or 3,    -   (b) determining the amount of the biomarker Procalcitonin (PCT)        in a sample from the patient,    -   (c) comparing the amounts determined in steps (b) and (c) to        reference amounts, and    -   (d) aiding in the risk assessment of a patient with suspected        sepsis.

Preferably, step (d) is based on the results of the comparison step (c).Accordingly, step (d) preferably comprises aiding in the risk assessmentof a patient with suspected sepsis, based on the results of thecomparison step.

The method of the present invention, preferably, is an in vitro method.Moreover, it may comprise steps in addition to those explicitlymentioned above. For example, further steps may relate to samplepre-treatments or evaluation of the results obtained by the method. Themethod of the present invention may be also used for monitoring,confirmation, and sub-classification of the subject. The method may becarried out manually or assisted by automation. Preferably, step (a),(b), (c) and/or (d) may in total or in part be assisted by automation,e.g., by a suitable robotic and sensory equipment for the determinationin step (a) and (b), or a computer-implemented comparison in step (c).

The methods of the present invention shall allow the assessment of apatient with suspected sepsis. The term “assessing” as used hereinpreferably refers to assessment of the risk of the patient with regardto the clinical course (i.e. need for critical care intervention) andoutcome. Thus, the outcome of predicted, i.e. whether the patient islikely, i.e. at risk, of having a poor outcome, or is not likely ofhaving a poor outcome Alternatively, the term “assessing” refers todeciding on suitable therapeutic measures for the patient (e.g.requiring critical care intervention). Thus, the term encompasses theguidance of a patient with suspected sepsis. Accordingly, suggestionsfor therapeutic measures which are specifically applicable to thepatient can be made. By carrying out the methods of the presentinvention, a patient can be identified who is in need of a certaintherapeutic measure, or not.

As will be understood by those skilled in the art, such an assessment isusually not intended to be correct for 100% of the subjects. Theexpression “assessment” typically requires that an assessment can bemade for a statistically significant portion of subjects in a proper andcorrect manner. Whether a portion is statistically significant can bedetermined without further ado by the person skilled in the art usingvarious well known statistic evaluation tools, e.g., determination ofconfidence intervals, p-value determination, Student's t-test,Mann-Whitney test etc. Details are found in Dowdy and Wearden,Statis-tics for Research, John Wiley & Sons, New York 1983. Preferredconfidence intervals are at least 90%, at least 95%, at least 97%, atleast 98%, or at least 99%. The p-values are, preferably, 0.1, 0.05,0.01, 0.005, or 0.0001.

It is to be understood that the actual assessment made in the methods ofthe present invention may comprise further steps such as theconfirmation of the assessment. Thus, the term “assessment”, preferably,is understood as an aid in the assessment. The final assessment may bemade by the attending physician, i.e. by the physician who treats theindividual.

In a preferred embodiment of the methods of the present invention, theassessment of a patient with suspected sepsis is a risk stratificationof the patient, i.e. the assessment of the risk of the tested patient.Accordingly, it is assessed, i.e. predicted, whether the patient is arisk, or not a risk. Accordingly, it is predicted whether the patient islikely to deteriorate (developing multi-organ failure) and having a pooroutcome, or is not likely to deteriorate and of having a poor outcome.Said poor outcome shall be associated with sepsis. For example, the riskof mortality, in particular in-hospital mortality, of a septic shock,severe sepsis and/or of a complicated clinical course is predicted.

In a preferred embodiment, the risk of a complicated clinical course isassessed. Thus, the method of the present invention allows for theprediction, whether a patient is at risk, or not at risk, of acomplicated clinical course. The risk of complicated clinical course is,preferably, associated with potentially worse outcome and increasedin-hospital mortality. Accordingly, the present invention also allowsfor the prediction of the risk of mortality of the tested patient,particular mortality due to sepsis.

The term “complicated clinical course” is well understood by the skilledperson. As used herein, the term is defined as the need for organsupport measures required during intensive care unit (ICU) stay, such asadministration of intravenous fluids, vasopressors, mechanicalventilation and renal replacement therapy. A patient having complicatedclinical course typically requires a longer hospitalization as comparedto a patient without complicated clinical course. In some embodiments, asubject who has a clinical complicated course is in need of intensivecare measures.

In another preferred embodiment, the risk of a mortality is assessed.Thus, the method of the present invention allows for the prediction,whether a patient is at risk, or not at risk, of mortality due tosepsis. Preferably, said mortality is in-hospital mortality. Further,the method of present invention allows for the prediction of the risk ofsevere sepsis and/or a septic shock. Thus, it can be assessed whether apatient is at risk of severe sepsis and/or a septic shock, or not.

The terms “assessing the risk” or “predicting the risk” are usedinterchangeably herein and preferably refer to assessing whether apatient is at risk, or is not at risk. Accordingly, the probabilityaccording to which a patient will have complicated clinical course willdie and/or will suffer from a septic shock and/or severe sepsis, inparticular within a certain predictive window after the method of thepresent invention has been carried out. Thus, the terms shall mean thatthe patient to be analyzed by the method of the present invention isallocated either into the group of patients being at risk, or into thegroup of patients being not at risk (such as of complicated clinicalcourse, mortality (in particular mortality due to sepsis) and/or aseptic shock and/or severe sepsis.

In particular, the risk/probability in a certain time window ispredicted, e.g. with regard to in-hospital mortality. It is to beunderstood that the risk that shall be predicted is the short-term risk,i.e. the predictive window is short. In an embodiment the risk of a pooroutcome within a period of up to 30 days is predicted. For example therisk of a poor outcome within a period of 3 days to 30 days, or of oneweek to 30 days, is predicted. In particular, the predictive window is aperiod of 30 days.

A patient who is at risk has an elevated risk as compared to the averagerisk, i.e. the patient is a high risk patient with potentially lifethreatening sepsis. In particular, the risk of the subject is elevatedas compared to the average risk of subjects having the same qSOFA scoreas the subject. A patient who is a risk, i.e. at high risk, is likely todeteriorate and of having a poor outcome and needs escalated care toprevent deterioration, i.e. critical care intervention.

A patient who is not at risk preferably has a reduced risk as comparedto the average risk, i.e. the patient is a low risk patient with a goodprognosis and low in-hospital mortality risk. In particular, the risk ofthe subject is reduced as compared to the average risk of subjectshaving the same qSOFA score as the subject. A patient who is not atrisk, i.e. a patient who is at low risk, is likely to have a goodoutcome.

The “subject” as referred to herein is, preferably, a mammal. Mammalsinclude, but are not limited to, domesticated animals (e.g., cows,sheep, cats, dogs, and horses), primates (e.g., humans and non-humanprimates such as monkeys), rabbits, and rodents (e.g., mice and rats).Preferably, the subject is a human subject. The term “patient” and“subject” are used interchangeably herein.

The subject to tested in accordance with the present invention presentwith suspected sepsis. The term “sepsis” is well-known in the art. Asused herein, the term refers a life-threatening organ dysfunction causedby a dysregulated host response to infection. Further, a definition forsepsis can be found in Singer et al. (Sepsis-3 The Third InternationalConsensus Definitions for Sepsis and Septic Shock. JAMA 2016;315:801-819). In particular, the subject shall be suspected to sufferfrom a systemic infection. The term “infection” is well understood bythe skilled person. As used herein, the term “infection” preferablyrefers to an invasion of the subject's body tissues by a disease-causingmicroorganism, its multiplication, and the reaction of subject's tissuesto the microorganism. In some embodiments, the infection is a bacterialinfection. Thus, the subject shall be suspected to suffer from bacterialsepsis.

A subject with suspected sepsis shows one or more of the followingsymptoms: faster heart beat (tachycardia), lower systolic blood pressure(hypotension), fever or hypothermia (often with chills), pain, reddenedskin, rapid breathing (tachypnoe), difficulty breathing (dyspnoe), innerunrest, dizziness and disorientation. Preferably, the subject has fever,i.e. the subject has a body temperature above the normal range due to anincrease in the body's temperature set point. For example, the subjectmight have a body temperature above 38° C. Alternatively, the subjectmight have a body temperature above 39° C.

Preferably, the subject with suspected sepsis is a subject who presentsat the emergency department. Alternatively, the subject with suspectedsepsis is a subject in departments outside of the intensive care unit.Thus, it is envisaged that the subject is not an intensive care patientat the time of the testing (or to be more precise at the time point atwhich the sample is obtained from the patient.

Preferably, the subject to be tested on accordance with the presentinvention shall have known qSOFA score (quick Sequential OrganFailure-Assessment score, also referred to as as quickSOFA). The qSOFAscore is well known in the art. It was introduced by the Sepsis-3 groupin February 2016 as a simplified version of the SOFA Score as an initialway to identify patients at high risk for poor outcome with sepsis. Thescore is described in by Singer et al. (JAMA. 2016; 315(8):801-810.doi:10.1001/jama.2016.0287) which herewith is incorporated by referencein its entirety with respect its disclosure content. The qSOFA scoreuses three criteria: assigning one point for low blood pressure (SBP≤100 mmHg), high respiratory rate (≥22 breaths per min), or alteredmentation (Glasgow Coma Scale score <15 points). Thus, the patient'sqSOFA score is based on the patient's respiratory rate, the patient'ssystolic blood pressure, and the presence or absence of an alteredmentation.

Typically, a subject has a low blood pressure if the systolic bloodpressure is equal to or lower than 100 mmHg. Typically, a subject has analtered mentation, if the subject's Glasgow Coma Scale score is lowerthan 15 points. Typically, a subject has a low blood pressure if thesystolic blood pressure is equal to or lower than 100 mmHg. Typically, asubject has a high respiratory rate, if the subject's respiratory rateis equal to or larger than 22 breaths per min.

In some embodiments, the subject has qSOFA score of 0.

In some embodiments, the subject has qSOFA score of 1.

In some embodiments, the subject has qSOFA score of 2.

In some embodiments, the subject has qSOFA score of 3.

In some embodiments, the subject has qSOFA score of 0 or 1

In some embodiments, the subject has qSOFA score of 2 or 3.

In some embodiments, the subject has qSOFA score of 0, 1, 2 or 3

In preferred embodiments of the methods of the present invention, thesubject's qSOFA score is known. Thus, the qSOFA score of the subject hasbeen determined, in particular at or shortly after presentation. In someembodiments, the methods of the present invention encompass thedetermination of the subject's qSOFA score. In some embodiments, themethods of the present invention do not encompass the determination ofthe subject's qSOFA score.

The term “sample” refers to a sample of a body fluid, to a sample ofseparated cells or to a sample from a tissue or an organ. Samples ofbody fluids can be obtained by well-known techniques and include,samples of blood, plasma, serum, urine, lymphatic fluid, sputum,ascites, or any other bodily secretion or derivative thereof. Preferredbody fluid samples are urine, blood, serum or plasma. Tissue or organsamples may be obtained from any tissue or organ by, e.g., biopsy.Separated cells may be obtained from the body fluids or the tissues ororgans by separating techniques such as centrifugation or cell sorting.E.g., cell-, tissue- or organ samples may be obtained from those cells,tissues or organs which express or produce the biomarker. The sample maybe frozen, fresh, fixed (e.g. formalin fixed), centrifuged, and/orembedded (e.g. paraffin embedded), etc. The cell sample can, of course,be subjected to a variety of well-known post-collection preparative andstorage techniques (e.g., nucleic acid and/or protein extraction,fixation, storage, freezing, ultrafiltration, concentration,evaporation, centrifugation, etc.) prior to assessing the amount of themarker in the sample.

Further, it is envisaged that the sample is a dried blood spot sample.Dried blood spot samples can be obtained by applying drops of blood ontoabsorbent filter paper. The blood is allowed to thoroughly saturate thepaper and is air dried for several hours. The blood may have been drawnby a lancet from the subject to be tested, e.g. from the finger.

In a preferred embodiment, the sample is a blood (i.e. whole blood),serum or plasma sample. Serum is the liquid fraction of whole blood thatis obtained after the blood is allowed to clot. For obtaining the serum,the clot is removed by centrifugation and the supernatant is collected.Plasma is the acellular fluid portion of blood. For obtaining a plasmasample, whole blood is collected in anticoagulant-treated tubes (e.g.citrate-treated or EDTA-treated tubes).

Cells are removed from the sample by centrifugation and the supernatant(i.e. the plasma sample) is obtained.

The methods of the present invention are based on the determination ofthe amounts of two biomarkers, Procalcitonin (abbreviated as PCT) andPresepsin.

Presepsin is also known as “soluble CD14 subtype” or “sCD14-ST” and isderived from sCD14 (soluble CD14), of which at least two forms of highermolecular weight exist (49 kDa and 55 kDa) and of which sCD14-ST is afragment. Proteolysis of sCD14 leads to formation of Presepsin. Themarker is well known in the art and e.g. review in Erenler et al.(Presepsin (sCD14-ST) as a biomarker of sepsis in clinical practice andin emergency department: a mini review. 2015 J Lab Med 39:367-372) whichherewith is incorporated by reference. Antibodies which specificallybind to Presepsin, preferably, without binding to sCD14 are available(see e.g. Okamura Y, Yokoi H. Development of a point-of-care assaysystem for measurement of presepsin (sCD14-ST). Clin Chim Acta. 2011;412(23-24):2157-61).

Procalcitonin (abbreviated PCT) is a peptide precursor of the hormonecalcitonin. Thus, it is the inactive propeptide of calcitonin. It iscomposed of 116 amino acids and is produced by parafollicular cells (Ccells) of the thyroid and by the neuroendocrine cells of the lung andthe intestine. PCT is widely reported as a useful biochemical marker todifferentiate sepsis from other non-infectious causes of systemicinflammation (Kondo, Y., Umemura, Y., Hayashida, K. et al. J intensivecare (2019) 7: 22. https://doi.org/10.1186/s40560-019-0374-4). The aminoacid sequence of the marker is well known in the art and is e.g.disclosed in EP2320237B1.

The term “amount” as used herein encompasses the absolute amount of abiomarker as referred to herein (such as PCT and Presepsin), therelative amount or concentration of the said biomarker as well as anyvalue or parameter which correlates thereto or can be derived therefrom.Such values or parameters comprise intensity signal values from allspecific physical or chemical properties obtained from the said peptidesby direct measurements, e.g., intensity values in mass spectra or NMRspectra. Moreover, encompassed are all values or parameters which areobtained by indirect measurements specified elsewhere in thisdescription, e.g., response amounts determined from biological read outsystems in response to the peptides or intensity signals obtained fromspecifically bound ligands. It is to be understood that valuescorrelating to the aforementioned amounts or parameters can also beobtained by all standard mathematical operations.

The term “determining” the amount of a biomarker as referred to hereinrefers to the quantification of the biomarker, e.g. to determining thelevel of the biomarker in the sample, employing appropriate methods ofdetection described elsewhere herein.

In an embodiment, the amount of a biomarker is determined by contactingthe sample with an agent that specifically binds to the biomarker,thereby forming a complex between the agent and said biomarker,detecting the amount of complex formed, and thereby determining theamount of said biomarker.

The biomarker as referred to herein can be detected using methodsgenerally known in the art. Methods of detection generally encompassmethods to quantify the amount of a biomarker in the sample(quantitative method). It is generally known to the skilled artisanwhich of the following methods are suitable for qualitative and/or forquantitative detection of a biomarker. Samples can be convenientlyassayed for, e.g., proteins using Westerns and immunoassays, likeELISAs, RIAs, fluorescence- and luminescence-based immunoassays, whichare commercially available. Further suitable methods to detect biomarkerinclude determining a physical or chemical property specific for thepeptide or polypeptide such as its precise molecular mass or NMRspectrum. Said methods comprise, e.g., biosensors, optical devicescoupled to immunoassays, biochips, analytical devices such asmass-spectrometers, NMR-analyzers, or chromatography devices. Further,methods include microtiter plate ELISA-based methods, fully-automated orrobotic immunoassays (available for example on Roche Elecsys™analyzers), and latex agglutination assays (available for example onRoche-Hitachi™ analyzers). In addition, LC-MS (LiquidChromatography-Mass Spectrometry) can be used for the detection andquantification of peptides and proteins in biological matrices.

For the detection of biomarker proteins as referred to herein a widerange of immunoassay techniques using such an assay format areavailable, see, e.g., U.S. Pat. Nos. 4,016,043, 4,424,279, and4,018,653. These include both single-site and two-site or “sandwich”assays of the non-competitive types, as well as in the traditionalcompetitive binding assays. These assays also include direct binding ofa labeled antibody to a target biomarker. Sandwich assays are among themost useful immunoassays.

Methods employing electrochemiluminescent labels are well-known. Suchmethods make use of the ability of special metal complexes to achieve,by means of oxidation, an excited state from which they decay to groundstate, emitting electrochemiluminescence. For review see Richter, M. M.,Chem. Rev. 104 (2004) 3003-3036.

In an embodiment, the detection antibody (or an antigen-binding fragmentthereof) to be used for determining the amount of a biomarker isruthenylated or iridinylated. Accordingly, the antibody (or anantigen-binding fragment thereof) shall comprise a ruthenium label. Inan embodiment, said ruthenium label is a bipyridine-ruthenium(II)complex. Or the antibody (or an antigen-binding fragment thereof) shallcomprise an iridium label. In an embodiment, said iridium label is acomplex as disclosed in WO 2012/107419.

Determining the amount of a peptide or polypeptide (such as PCT orPresepsin) may, preferably, comprise the steps of (a) contacting thepeptide or polypeptide with an agent that specifically binds saidpolypeptide (b) (optionally) removing non-bound agent, (c) determiningthe amount of bound binding agent, i.e. the complex of the agent formedin step (a). According to a preferred embodiment, said steps ofcontacting, optionally removing and determining may be performed by ananalyzer unit. According to some embodiments, said steps may beperformed by a single analyzer unit of said system or by more than oneanalyzer unit in operable communication with each other. For example,according to a specific embodiment, said system disclosed herein mayinclude a first analyzer unit for performing said steps of contactingand optionally removing and a second analyzer unit, operably connectedto said first analyzer unit by a transport unit (for example, a roboticarm), which performs said step of determining.

The agent which specifically binds the biomarker (herein also referredto as “binding agent”) may be coupled covalently or non-covalently to alabel allowing detection and measurement of the bound agent. Labelingmay be done by direct or indirect methods. Direct labeling involvescoupling of the label directly (covalently or non-covalently) to thebinding agent. Indirect labeling involves binding (covalently ornon-covalently) of a secondary binding agent to the first binding agent.The secondary binding agent should specifically bind to the firstbinding agent. Said secondary binding agent may be coupled with asuitable label and/or be the target (receptor) of tertiary binding agentbinding to the secondary binding agent.

Suitable secondary and higher order binding agents may includeantibodies, secondary antibodies, and well-known binding-systems such asthe streptavidin-biotin system (Vector Laboratories, Inc.). The bindingagent or substrate may also be “tagged” with one or more tags as knownin the art. Such tags may then be targets for higher order bindingagents. Suitable tags include biotin, digoxygenin, His-Tag,Glutathion-S-Transferase, FLAG, GFP, myc-tag, influenza A virushaemagglutinin (HA), maltose binding protein, and the like. In the caseof a peptide or polypeptide, the tag is preferably at the N-terminusand/or C-terminus. Suitable labels are any labels detectable by anappropriate detection method. Typical labels include gold particles,latex beads, acridan ester, luminol, ruthenium complexes, iridiumcomplexes, enzymatically active labels, radioactive labels, magneticlabels (“e.g. magnetic beads”, including paramagnetic andsuperparamagnetic labels), and fluorescent labels. Enzymatically activelabels include e.g. horseradish peroxidase, alkaline phosphatase,beta-Galactosidase, Luciferase, and derivatives thereof. Suitablesubstrates for detection include di-amino-benzidine (DAB),3,3′-5,5′-tetramethylbenzidine, NBT-BCIP (4-nitro blue tetrazoliumchloride and 5-bromo-4-chloro-3-indolyl-phosphate, avail-able asready-made stock solution from Roche Diagnostics), CDP-Star™ (AmershamBio-sciences), ECF™ (Amersham Biosciences). A suitable enzyme-substratecombination may result in a colored reaction product, fluorescence orchemoluminescence, which can be determined according to methods known inthe art (e.g. using a light-sensitive film or a suit-able camerasystem). As for determining the enzymatic reaction, the criteria givenabove apply analogously. Typical fluorescent labels include fluorescentproteins (such as GFP and its derivatives), Cy3, Cy5, Texas Red,Fluorescein, and the Alexa dyes (e.g. Alexa 568). Further fluorescentlabels are available e.g. from Molecular Probes (Oregon). Also the useof quantum dots as fluorescent labels is contemplated. A radioactivelabel can be detected by any method known and appropriate, e.g. alight-sensitive film or a phosphor imager.

The amount of a polypeptide may be, also preferably, determined asfollows: (a) contacting a solid support comprising a binding agent forthe polypeptide as described elsewhere herein with a sample comprisingthe peptide or polypeptide and (b) determining the amount of peptide orpolypeptide which is bound to the support. Materials for manufacturingsupports are well-known in the art and include, inter alia, commerciallyavailable column materials, polystyrene beads, latex beads, magneticbeads, colloid metal particles, glass and/or silicon chips and surfaces,nitrocellulose strips, membranes, sheets, duracytes, wells and walls ofreaction trays, plastic tubes etc.

In yet an aspect the sample is removed from the complex formed betweenthe binding agent and one marker prior to the measurement of the amountof formed complex. Accordingly, in an aspect, the binding agent may beimmobilized on a solid support. In yet an aspect, the sample can beremoved from the formed complex on the solid support by applying awashing solution.

“Sandwich assays” are among the most useful and commonly used assaysencompassing a number of variations of the sandwich assay technique.Briefly, in a typical assay, an unlabeled (capture) binding agent isimmobilized or can be immobilized on a solid substrate, and the sampleto be tested is brought into contact with the capture binding agent.After a suitable period of incubation, for a period of time sufficientto allow formation of a binding agent-biomarker complex, a second(detection) binding agent labeled with a reporter molecule capable ofproducing a detectable signal is then added and incubated, allowing timesufficient for the formation of another complex of bindingagent-biomarker-labeled binding agent. Optionally, any unreactedmaterial may be washed away. The presence of the biomarker is determinedby observation of a signal produced by the reporter molecule bound tothe detection binding agent. The results may either be qualitative, bysimple observation of a visible signal, or may be quantitated bycomparison with a control sample containing known amounts of biomarker.

The incubation steps of a typical sandwich assays can be varied asrequired and appropriate. Such variations include for examplesimultaneous incubations, in which two or more of binding agent andbiomarker are co-incubated. For example, both, the sample to be analyzedand a labeled binding agent are added simultaneously to an immobilizedcapture binding agent. It is also possible to first incubate the sampleto be analyzed and a labeled binding agent and to thereafter add anantibody bound to a solid phase or capable of binding to a solid phase.

The formed complex between a specific binding agent and the biomarkershall be proportional to the amount of the biomarker present in thesample. It will be understood that the specificity and/or sensitivity ofthe binding agent to be applied defines the degree of proportion of atleast one marker comprised in the sample which is capable of beingspecifically bound. Further details on how the measurement can becarried out are also found elsewhere herein. The amount of formedcomplex shall be transformed into an amount of the biomarker reflectingthe amount indeed present in the sample.

In some embodiments, the amount of Presepsin is determined with thePathfast Presep sin assay from LSI Medience Corporation (13-4, Uchikanda1-chome, Chiyoda-ku, Tokyo, Japan, Product No. PF 1201-K).

In some embodiments, the amount of PCT is determined with the Elecsys®BRAHMS PCT assay from Roche Diagnostics GmbH, 68305 Mannheim, Germany.

The terms “binding agent”, “specific binding agent”, “analyte-specificbinding agent”, “detection agent” and “agent that specifically binds toa biomarker” are used interchangeably herein. Preferably, it relates toan agent that comprises a binding moiety which specifically binds thecorresponding biomarker. Examples of “binding agents” or “agents” are anucleic acid probe, nucleic acid primer, DNA molecule, RNA molecule,aptamer, antibody, antibody fragment, peptide, peptide nucleic acid(PNA) or chemical compound. A preferred agent is an antibody, orantigen-binding fragment thereof, which specifically binds to thebiomarker to be determined. The term “antibody” herein is used in thebroadest sense and encompasses various antibody structures, includingbut not limited to monoclonal antibodies, polyclonal antibodies,multispecific antibodies (e.g., bispecific antibodies), and antibodyfragments as long as they exhibit the desired antigen-binding activity(i.e. antigen-binding fragments thereof). Preferably, the antibody is apolyclonal antibody. More preferably, the antibody is a monoclonalantibody.

The term “specific binding” or “specifically bind” refers to a bindingreaction wherein binding pair molecules exhibit a binding to each otherunder conditions where they do not significantly bind to othermolecules. The term “specific binding” or “specifically binds”, whenreferring to a protein or peptide as biomarker, refers to a bindingreaction wherein a binding agent binds to the corresponding biomarkerwith an affinity of at least 10⁻⁷ M. The term “specific binding” or“specifically binds” preferably refers to an affinity of at least 10⁻⁷ Mor even more preferred of at least 10⁻⁹ M for its target molecule. Theterm “specific” or “specifically” is used to indicate that othermolecules present in the sample do not significantly bind to the bindingagent specific for the target molecule.

The term “comparing” as used herein refers to comparing the amount ofthe biomarker in the sample from the subject with the reference amountof the biomarker specified elsewhere in this description. It is to beunderstood that comparing as used herein usually refers to a comparisonof corresponding parameters or values, e.g., an absolute amount iscompared to an absolute reference amount while a concentration iscompared to a reference concentration or an intensity signal obtainedfrom the biomarker in a sample is compared to the same type of intensitysignal obtained from a reference sample. The comparison may be carriedout manually or computer-assisted. Thus, the comparison may be carriedout by a computing device. The value of the determined or detectedamount of the biomarker in the sample from the subject and the referenceamount can be, e.g., compared to each other and the said comparison canbe automatically carried out by a computer program executing analgorithm for the comparison. The computer program carrying out the saidevaluation will provide the desired assessment in a suitable outputformat. For a computer-assisted comparison, the value of the determinedamount may be compared to values corresponding to suitable referenceswhich are stored in a database by a computer program. The computerprogram may further evaluate the result of the comparison, i.e.automatically provide the desired assessment in a suitable outputformat. For a computer-assisted comparison, the value of the determinedamount may be compared to values corresponding to suitable referenceswhich are stored in a database by a computer program. The computerprogram may further evaluate the result of the comparison, i.e.automatically provides the desired assessment in a suitable outputformat.

In accordance with the present invention the amount of the biomarker PCTand the biomarker Presepsin shall be compared to a reference. Typically,the amount of the biomarker PCT is compared to a reference for PCT, andthe amount of the biomarker Presepsin is compared to a reference forPresepsin.

The reference is preferably a reference amount. The term “referenceamount” as used herein refers to an amount which allows for allocationof a subject into either (i) the group of subjects being at risk or (ii)the group of being not at risk (e.g. of a complicated clinical course).A suitable reference amount may be determined from a reference sample tobe analyzed together, i.e. simultaneously or subsequently, with the testsample.

Reference amounts can, in principle, be calculated for a cohort ofsubjects as specified above based on the average or mean values for agiven biomarker by applying standard methods of statistics. Inparticular, accuracy of a test such as a method aiming to diagnose anevent, or not, is best described by its receiver-operatingcharacteristics (ROC) (see especially Zweig 1993, Clin. Chem.39:561-577). The ROC graph is a plot of all of the sensitivity versusspecificity pairs resulting from continuously varying the decisionthreshold over the entire range of data observed. The clinicalperformance of a prognostic method depends on its accuracy, i.e. itsability to correctly allocate subjects to a certain prognosis. The ROCplot indicates the overlap between the two distributions by plotting thesensitivity versus 1- specificity for the complete range of thresholdssuitable for making a distinction. On the y-axis is sensitivity, or thetrue-positive fraction, which is defined as the ratio of number oftrue-positive test results to the product of number of true-positive andnumber of false-negative test results. This has also been referred to aspositivity in the presence of a disease or condition. It is calculatedsolely from the affected subgroup. On the x-axis is the false-positivefraction, or 1—specificity, which is defined as the ratio of number offalse-positive results to the product of number of true-negative andnumber of false-positive results. It is an index of specificity and iscalculated entirely from the unaffected subgroup. Because the true- andfalse-positive fractions are calculated entirely separately, by usingthe test results from two different subgroups, the ROC plot isindependent of the prevalence of the event in the cohort. Each point onthe ROC plot represents a sensitivity/1—specificity pair correspondingto a particular decision threshold. A test with perfect discrimination(no overlap in the two distributions of results) has an ROC plot thatpasses through the upper left corner, where the true-positive fractionis 1.0, or 100% (perfect sensitivity), and the false-positive fractionis 0 (perfect specificity). The theoretical plot for a test with nodiscrimination (identical distributions of results for the two groups)is a 45° diagonal line from the lower left corner to the upper rightcorner. Most plots fall in between these two extremes. If the ROC plotfalls completely below the 45° diagonal, this is easily remedied byreversing the criterion for “positivity” from “greater than” to “lessthan” or vice versa. Qualitatively, the closer the plot is to the upperleft corner, the higher the overall accuracy of the test. Dependent on adesired confidence interval, a threshold can be derived from the ROCcurve allowing for the diagnosis for a given event with a proper balanceof sensitivity and specificity, respectively. Accordingly, the referenceto be used for the aforementioned method of the present invention, i.e.a threshold which allows to differentiating between subjects who are atrisk or those who are not at risk among a cohort of subjects withsuspected sepsis can be generated, preferably, by establishing a ROC forsaid cohort as described above and deriving a threshold amounttherefrom. Dependent on a desired sensitivity and specificity for adiagnostic method, the ROC plot allows deriving a suitable threshold. Itwill be understood that an optimal sensitivity is desired for excludinga subject who is at risk, (i.e. a rule out) whereas an optimalspecificity is envisaged for a subject to be assessed as being at risk(i.e. a rule in).

In certain embodiments, the term “reference amount” as used hereinrefers to a predetermined value. Said predetermined value shall allowfor differentiating between a subject who is at risk and a subject whois not at risk (such as of a complicated clinical course).

For example, the reference amount for Presepsin is within the range fromabout 500 pg/mL to about 1500 pg/mL. Preferably, the reference amountfor Presepsin is within the range from about 750 pg/mL to about 1250pg/mL, more preferably within the range from about 850 pg/mL to about1150 pg/mL, even more preferably within the range from about 950 pg/mLto about 1050 pg/mL. Most preferably, the reference amount is about 1000pg/mL.

Preferably, the reference amount for PCT is within the range from about1.5 ng/mL to about 2.5 ng/mL, more preferably within the range fromabout 1.75 ng/mL to about 2.25 ng/mL, even more preferably within therange from about 1.9 ng/mL to about 2.1 ng/mL. Most preferably, thereference amount for PCT is about 2 ng/mL.

In the following preferred diagnostic algorithms are summarized.

Preferably, an amount of Presepsin in the sample from the subject whichis larger than the reference amount for Presepsin and/or an amount ofPCT in the sample from the subject which is larger than the referenceamount for PCT is indicative for a subject who is at risk (in particularof a complicated clinical course). Thus, a subject is at risk, if i) theamount of Presepsin is increased, if ii) the amount of PCT is increased,or if iii) both the amounts of Presepsin and PCT are increased ascompared to the corresponding reference.

Additionally or alternatively, an amount of Presepsin in the sample fromthe subject which is lower than the reference amount for Presepsin andan amount of PCT in the sample from the subject which is lower than thereference amount for PCT is indicative for a subject who is at not atrisk (in particular of a complicated clinical course). Thus, the subjectis not at risk if both the amounts of Presepsin and PCT are decreased ascompared to the corresponding reference.

The rule in of the risk is particularly advantageous for subjects with a“negative” qSOFA score, such as for subjects with a qSOFA score of 0or 1. In a preferred embodiment, the subject thus has a (known) qSOFAscore of 0 or 1, wherein an amount of Presepsin in the sample from thesubject which is larger than the reference amount for Presepsin and/oran amount of PCT in the sample from the subject which is larger than thereference amount for PCT is indicative for a subject who is at risk.

The rule out of the risk is particularly advantageous for subjects witha “positive” qSOFA score, such as for subjects with a qSOFA score of 2or 3. In a preferred embodiment, the subject thus has a (known) qSOFAscore of 2 or 3, an amount of Presepsin in the sample from the subjectwhich is lower than the reference amount for Presepsin and an amount ofPCT in the sample from the subject which is which is lower than thereference amount for PCT is indicative for a subject who is at not atrisk (in particular of a complicated clinical course).

In a preferred embodiment of the methods of the present invention, themethods further comprise recommending or initiating a suitabletherapeutic measure. Preferably, said suitable therapeutic measure isselected from the medical guidelines or recommendations for managementof sepsis such as International Guidelines for Management of Sepsis andSeptic Shock (Intensive Care Med, 2017). In particular, the therapeuticmeasure may be treatment of sepsis or further diagnostic investigationor other aspects of care deemed necessary by the practitioners.

In an embodiment, the therapeutic measure to be recommended or initiatedif a patient has been assessed to be at risk is selected from

-   -   administration of empiric broad spectrum therapy with at least        one or more (i.e. combination therapy) antimicrobial agents such        as a cephalosporine, a beta-lactam/beta-lactamase inhibitor        (e.g. piperacillin) and a carbapenem, preferably depending on        the organisms that are considered likely pathogens and        antibiotic susceptibilities    -   fluid resuscitation    -   administration of one or more vasopressors, such as        administration of norepinephrine    -   administration of one or more corticosteroids, such as        administration of hydrocortisone    -   renal replacement therapy, such as dialysis, and/or    -   mechanical ventilation.

The definitions and explanations given herein above preferably applymutatis mutandis to the following methods of the present invention.

As set forth above, the above method of the present invention mayencompass obtaining or the determination of the patients's qSOFA score.Accordingly, the present invention relates to a method for aiding in therisk assessment of a patient with suspected sepsis, comprising

-   -   (a) obtaining or determining the patient's qSOFA (quick        Sequential Organ Failure-Assessment) score,    -   (b) determining the amount of the biomarker Presepsin in a        sample from the patient with suspected sepsis    -   (c) determining the amount of the biomarker Procalcitonin (PCT)        in a sample from the patient,    -   (d) comparing the amounts determined in steps (b) and (c) to        reference amounts, and    -   (e) aiding in the risk assessment of the patient.

Preferably, step (e) is based on the qSOFA score obtained or determinedin step (a) and on the results of the comparison step (c). Accordingly,step (e) preferably comprises aiding in the risk assessment of a patientwith suspected sepsis based on both the qSOFA score and on the resultsof the comparison step.

The determination of the patient's qSOFA score preferably encompassesthe assessment of the patient's respiratory rate, the patient's systolicblood pressure, and the assessment of presence or absence of an alteredmentation in the patient, and the calculation of the qSOFA score basedon the aforementioned assessment.

Obtaining the patient's qSOFA score preferably means receiving a valuefor the patient's qSOFA score. Thus, obtaining the patient's qSOFA scoredoes not encompass any active diagnostic steps.

The methods of the present invention may be also carried out ascomputer-implemented inventions.

Accordingly, the present invention relates to a computer-implementedmethod for the assessment of a patient with suspected sepsis, comprising

-   -   (a) receiving at a processing unit        -   (a1) a value for the amount of the biomarker Presepsin in a            sample from a patient with suspected sepsis who has a known            qSOFA (quick Sequential Organ Failure-Assessment) score of            0, 1, 2 or 3 and        -   (a2) a value for the amount of the biomarker Procalcitonin            in a sample from the patient,    -   (b) processing the values received in step (a) with the        processing unit, wherein said processing comprises        -   (b1) retrieving from a memory one or more threshold values            for the amount of the biomarker Presepsin, and one or more            threshold values for the amount of the biomarker            Procalcitonin,        -   (b2) comparing the values received in step (a) with the            respective threshold values retrieved in step (b1), and    -   (c) providing an assessment of the patient via an output device,        wherein said assessment is based on the results of step b).

Alternatively, the present invention relates to computer-implementedmethod for the assessment of a patient with suspected sepsis, comprising

-   -   (a) receiving at a processing unit        -   (a1) a value for the patient's qSOFA (quick Sequential Organ            Failure-Assessment) score,        -   (a2) a value for the amount of the biomarker Presepsin in a            sample from the patient, and        -   (a3) a value for the amount of the biomarker Procalcitonin            in a sample from the patient,    -   (b) processing the values received in step (a) with the        processing unit, wherein said processing comprises        -   (b1) retrieving from a memory a threshold value for the            qSOFA score, one or more threshold values for the amount of            the biomarker Presepsin, and one or more threshold values            for the amount of the biomarker Procalcitonin,        -   (b2) comparing the values received in step (a) with the            respective threshold values retrieved in step (b 1), and    -   (c) providing an assessment of the patient via an output device,        wherein said assessment is based on the results of step b).

In an embodiment of the methods of the present invention, information onthe assessment (according to the last step of the methods of the presentinvention) is provided via a display, configured for presenting theassessment. Accordingly, information may be provided whether the subjectwith suspected sepsis is at risk for developing a complicated clinicalcourse, or is not at risk as described elsewhere herein. Further,recommendations for suitable therapeutic can be displayed. As describedelsewhere herein, various alternative therapeutic measures may berecommended. In this case, the treatment option or treatment option(s)may be shown in the display

In an embodiment of the methods of the present invention, the methodsmay comprise the further step of transferring the information on theassessment of the methods of the present invention to the subject'selectronic medical records.

Alternatively, the assessment made in the last step of the methods ofthe present invention can be printed by a printer. The print-out shallcontain information on whether the patient is at risk, or not at riskand/or a recommendation of a suitable therapeutic measure.

In an embodiment of the methods of the present invention, a subject whohas been identified as being at risk, or not at risk of a complicatedclinical course is treated based on the risk. Thus, a suitabletherapeutic measure is initiated, depending on whether the subject is atrisk or is not at risk.

The present invention thus further relates to a method of treating apatient with suspected sepsis, the method comprising, carrying out anyof the methods of the present invention for assessing a patient withsuspected sepsis, thereby identifying an individual who is at risk ornot at risk, and initiating a suitable therapeutic method.

The present invention further relates to computer program includingcomputer-executable instructions for performing the steps of the methodaccording to the present invention of assessing a subject with suspectedsepsis, when the program is executed on a computer or computer network.Typically, the computer program specifically may containcomputer-executable instructions for performing the steps of the methodas disclosed herein. Specifically, the computer program may be stored ona computer-readable data carrier.

The present invention further relates to computer program product withprogram code means stored on a machine-readable carrier, in order toperform the method according to present invention, when the program isexecuted on a computer or computer network, such as one or more of theabove-mentioned steps discussed in the context of the computer program.As used herein, a computer program product refers to the program as atradable product. The product may generally exist in an arbitraryformat, such as in a paper format, or on a computer-readable datacarrier. Specifically, the computer program product may be distributedover a data network.

The present invention further relates to a computer or computer networkcomprising at least one processing unit, wherein the processing unit isadapted to perform all steps of the computer-implemented methodaccording to the present invention.

Yet, the present invention also contemplates:

-   -   A computer or computer network comprising at least one        processing unit, wherein said processing unit is adapted to        perform the method according to one of the embodiments described        in this description,    -   a computer loadable data structure that is adapted to perform        the method according to one of the embodiments described in this        description while the data structure is being executed on a        computer,    -   a computer script, wherein the computer program is adapted to        perform the method according to one of the embodiments described        in this description while the program being executed on a        computer,    -   a computer program comprising program means for performing the        method according to one of the embodiments described in this        description while the computer program is being executed on a        computer or on a computer network,    -   a computer program comprising program means according to the        preceding embodiment, wherein the program means are stored on a        storage medium readable to a computer,    -   a storage medium, wherein a data structure is stored on the        storage medium and wherein the data structure is adapted to        perform the method according to one of the embodiments described        in this description after having been loaded into a main and/or        working storage of a computer or of a computer network,    -   a computer program product having program code means, wherein        the program code means can be stored or are stored on a storage        medium, for performing the method according to one of the        embodiments described in this description, if the program code        means are executed on a computer or on a computer network,    -   a data stream signal, typically encrypted, comprising glucose        data measurements obtained from the individual as specified        herein above, and a data stream signal, typically encrypted,        comprising an information providing an aid in the assessment of        guidance obtained by the method of the invention.

The present invention further relates to a device for assessing asubject with suspected sepsis, said device comprising a processing unit,and a computer program including computer-executable instructions,wherein said instructions, when executed by the processing unit, causesthe processing unit to perform the computer-implemented method accordingto the present invention, i.e. to perform the steps of said method. Inan embodiment, steps a) to d) of the method of the present invention areperformed by the processing unit. The device may further comprise a userinterface and a display, wherein the processing unit is coupled to theuser interface and the display. Typically, the device provides as outputthe assessment of the patient and/or a recommendation for a suitabletherapeutic measure. In an embodiment, the output is provided on thedisplay.

The present invention further relates to i) the use of PCT and Presepsinas biomarkers, or to ii) the use of at least one detection agent whichspecifically binds to PCT and of at least one detection agent whichspecifically binds to Presepsin, for assessing the risk of a patientwith suspected sepsis, wherein said patient has a known qSOFA score of0, 1, 2 or 3. Preferably, said use in an in vivo use.

Preferred detection agents are disclosed elsewhere herein (such asantibodies, or antigen binding fragments thereof).

List of Embodiments

In the following, preferred embodiments are summarized. The definitionsand explanations given herein above preferably apply mutatis mutandis tothe following embodiments.

-   1. A method for aiding in the risk assessment of a patient with    suspected sepsis, comprising    -   (a) determining the amount of the biomarker Presepsin in a        sample from a patient with suspected sepsis who has a known        qSOFA (quick Sequential Organ Failure-Assessment) score of 0, 1,        2 or 3    -   (b) determining the amount of the biomarker Procalcitonin (PCT)        in a sample from the patient,    -   (c) comparing the amounts determined in steps (b) and (c) to        reference amounts, and    -   (d) aiding in the risk assessment of a patient with suspected        sepsis.-   2. The method of embodiment 1, wherein the patient is a human    patient.-   3. The method of embodiments 1 and 2, wherein the sample is a blood,    serum or plasma sample.-   4. The method of embodiments 1 to 3, wherein the patient is a    patient who presents with suspected sepsis.-   5. The method of any one of embodiments 1 to 4, wherein the risk of    mortality, such as in-hospital mortality, a complicated clinical    course, severe sepsis and/or septic shock is assessed.-   6. The method of embodiment 5, wherein the complicated clinical    course is defined as the need for organ support measures required    during intensive care unit (ICU) stay, such as administration of    intravenous fluids, vasopressors, mechanical ventilation or renal    replacement therapy.-   7. The method of any one of embodiments 1 to 6, wherein the subject    has a known qSOFA (quick Sequential Organ Failure-Assessment) score    of 0 or 1.-   8. The method of embodiment 7, wherein an amount of Presepsin in the    sample from the subject which is larger than the reference amount    for Presepsin and/or an amount of PCT in the sample from the subject    which is larger than the reference amount for PCT is indicative for    a subject who is at risk.-   9. The method of embodiment 7, wherein an amount of Presepsin in the    sample from the to subject which is lower than the reference amount    for Presepsin and an amount of PCT in the sample from the subject    which is which is lower than the reference amount for PCT is    indicative for a subject who is at not at risk.-   10. The method of any one of embodiments 1 to 6, wherein the subject    has a known qSOFA (quick Sequential Organ Failure-Assessment) score    of 2 or 3.-   11. The method of embodiment 10, wherein an amount of Presepsin in    the sample from the subject which is larger than the reference    amount for Presepsin and/or an amount of PCT in the sample from the    subject which is larger than the reference amount for PCT is    indicative for a subject who is at risk.-   12. The method of embodiment 10, wherein an amount of Presepsin in    the sample from the subject which is lower than the reference amount    for Presepsin and an amount of PCT in the sample from the subject    which is which is lower than the reference amount for PCT is    indicative for a subject who is at not at risk.-   13. The method of any one of embodiments 1 to 12, further comprising    recommending or initiating a suitable therapeutic measure.-   14. The method of embodiment 13, wherein the therapeutic measure is    selected from recommended guidelines for management of sepsis, if    the subject has been assessed to be at risk.-   15. The method of embodiment 13, wherein the therapeutic measure may    be treatment of infection or further investigation or other aspects    of care deemed necessary by the practitioners, if the subject has    been assessed to be not at risk.-   16. The method of any one of embodiments 1 to 15, wherein the    reference amount for Presepsin is within the range from about 500    pg/mL to about 1500 pg/mL, or about 750 pg/mL to about 1250 pg/mL,    e.g. wherein the reference amount for Presepsin is about 1000 pg/mL,    and/or wherein the reference amount for PCT is within the range from    about 1.5 ng/mL to about 2.5 ng/mL, e.g. wherein the reference    amount for PCT is about 2 ng/mL.-   17. A method for aiding in the risk assessment of a patient with    suspected sepsis, comprising    -   (a) obtaining the patient's qSOFA (quick Sequential Organ        Failure-Assessment) score,    -   (b) determining the amount of the biomarker Presepsin in a        sample from the patient with suspected sepsis    -   (c) determining the amount of the biomarker Procalcitonin (PCT)        in a sample from the patient,    -   (d) comparing the amounts determined in steps (b) and (c) to        reference amounts, and    -   (e) aiding in the risk assessment of the patient.-   18. The method of embodiment 17, wherein the patient's qSOFA score    is based on the patient's respiratory rate (>22/min), the patient's    systolic blood pressure (<100 mmHg), and the presence or absence of    an altered mentation (GCS <15).-   19. A computer-implemented method for the assessment of a patient    with suspected sepsis, comprising    -   (a) receiving at a processing unit        -   (a1) a value for the amount of the biomarker Presepsin in a            sample from a patient with suspected sepsis who has a known            qSOFA (quick Sequential Organ Failure-Assessment) score of            0, 1, 2 or 3 and        -   (a2) a value for the amount of the biomarker Procalcitonin            in a sample from the patient,    -   (b) processing the values received in step (a) with the        processing unit, wherein said processing comprises        -   (b1) retrieving from a memory one or more threshold values            for the amount of the biomarker Presepsin, and one or more            threshold values for the amount of the biomarker            Procalcitonin,        -   (b2) comparing the values received in step (a) with the            respective threshold values retrieved in step (b 1), and    -   (c) providing an assessment of the patient via an output device,        wherein said assessment is based on the results of step b).-   20. A computer-implemented method for the assessment of a patient    with suspected sepsis, comprising    -   (a) receiving at a processing unit        -   (a1) a value for the patient's qSOFA (quick Sequential Organ            Failure-Assessment) score,        -   (a2) a value for the amount of the biomarker Presepsin in a            sample from the patient, and        -   (a3) a value for the amount of the biomarker Procalcitonin            in a sample from the patient,    -   (b) processing the values received in step (a) with the        processing unit, wherein said processing comprises        -   (b1) retrieving from a memory a threshold value for the            qSOFA score, one or more threshold values for the amount of            the biomarker Presepsin, and one or more threshold values            for the amount of the biomarker Procalcitonin,        -   (b2) comparing the values received in step (a) with the            respective threshold values retrieved in step (b 1), and    -   (c) providing an assessment of the patient via an output device,        wherein said assessment is based on the results of step b).-   21. The method of embodiment 19 or 20, wherein the output device is    a display, configured for presenting the assessment.-   22. The method of any one of embodiments 19 to 22, wherein the value    for the amount of the biomarker Presepsin and/or Procalcitonin is    the value for the amount of the biomarker in a blood, serum or    plasma sample.-   23. The method of any one of embodiments 1 to 22, wherein the    patient with suspected sepsis shows one or more of the following    symptoms: tachycardia, hypotension, fever or hypothermia, pain,    reddened skin, tachypnoe, dyspnoe, inner unrest, dizziness and    disorientation, and/or wherein the patient's qSOFA score is based on    the patient's respiratory rate (>22/min), the patient's systolic    blood pressure (<100 mmHg), and the presence or ab-sence of an    altered mentation (GCS <15).-   24. A device for the assessment of a patient with suspected sepsis,    said device comprising a processing unit and a computer program    including computer-executable instructions, wherein said    instructions, when executed by the processing unit, causes the    processing unit to perform the computer-implemented method of any    one of embodiments 19 to 23.-   25. The device of embodiment 24, wherein the processing is coupled    to a user interface and a display.-   26. A method for the assessment of a patient with suspected sepsis,    comprising    -   (a) obtaining a value for the patient's qSOFA (quick Sequential        Organ Failure-Assessment) score,    -   (b) determining the amount of the biomarker Presepsin in a        sample from the patient,    -   (c) determining the amount of the biomarker Procalcitonin in a        sample from the patient,    -   (d) comparing the value obtained in step a) to a reference        value, comparing the amounts determined in steps (b) and (c) to        reference amounts, and    -   (e) assessing the patient based on the results of step d).-   27. A method for improving the accuracy of the qSOFA score,    comprising    -   (a) determining the amount of the biomarker Presepsin in a        sample from a patient having a known qSOFA score of 0, 1, 2 or        3,    -   (b) determining the amount of the biomarker Procalcitonin in a        sample from the patient,    -   (c) comparing the amounts determined in steps (a) and (b) to        reference amounts, and    -   (d) improving the accuracy of the qSOFA score based on the        results of step (c).-   28. Use of PCT and Presepsin as biomarker, or to ii) the use of at    least one detection agent which specifically binds to PCT and of at    least one detection agent which specifically binds to Presepsin, for    assessing the risk of a patient with suspected sepsis, wherein said    patient has a known qSOFA score of 0, 1, 2 or 3.

All references cited in this specification are herewith incorporated byreference with respect to their entire disclosure content and thedisclosure content specifically mentioned in this specification.

In the Figures:

FIG. 1 Combined assessment of Presepsin (PSEP) and Procalcitonin (PCT)in addition to the qSOFA score improves the prediction of a complicatedclinical course (severe sepsis, septic shock and mortality) in patientswith early sepsis admitted to the emergency department

EXAMPLES

The invention will be merely illustrated by the following Examples. Thesaid Examples shall, whatsoever, not be construed in a manner limitingthe scope of the invention.

Example 1: Assessment of Presepsin (PSEP), Procalcitonin (PCT) and theQuick SOFA Score in Patients with Suspected Sepsis

Presepsin (soluble sCD14 subtype, sCD14-ST) is a circulating moleculefragment derived from sCD14 and serves as mediator of lipopolysaccharid(LPS) response against infectious agents. Presepsin has been shown to bebeneficial as sepsis marker.

PCT is a member of the calcitonin (CT) superfamily of peptides. Due toPCT's variance between microbial infections and healthy individuals, ithas become a marker to improve identification of systemic bacterialinfection. Measurement of Procalcitonin can be used as a marker ofsevere sepsis caused by bacteria and correlates with the degree ofsepsis.

The Sequential Organ Failure Assessment (SOFA) score was documented aswell as respiratory rate, systolic blood pressure (RRsyst) and alteredmentation (GCS score) enabling the calculation of the Quick SOFA (qSOFA)score retrospectively.

In 99 patients with suspected sepsis admitted to the emergencydepartment (ED) Presepsin (PSEP), Procalcitonin (PCT) and the SOFA scorewere determined upon admission. Additional measured parameters were CRP,creatinine and lactate. The Sequential Organ Failure Assessment (SOFA)score was documented as well as respiratory rate, systolic bloodpressure (RRsyst) and altered mentation (GCS score) to calculate theQuick SOFA (qSOFA) score retrospectively. Primary endpoint was deathwithin 30 days. The combined endpoint “major adverse event” (MAE)consisted of at least one of the primary or the secondary endpoints(EP)—need of intensive care (ITS), mechanical ventilation or dialysis.EDTA plasma samples were collected at first presentation.

Example 2: Results

Median values of PSEP and PCT were 688 (IQR: 391-1143) pg/mL, and 1.39(IQR: 0.385-4.29) ng/mL in the group with uncomplicated sepsis (N=66)and 1266 (IQR: 746-2267) pg/mL, p=0.0003, and 2.73 (IQR: 0.90-16.5)ng/mL in patients with septic shock or with complicated clinical course,p=0.0242, respectively. The 30-day mortality was 18.1% (n=18) overall,but in the group with septic shock 36.6% (n=15). The discriminationbetween survivors (n=81) and non-survivors (n=18) by ROC analysisrevealed AUC values of 0.772, 0.519 and 0.802 of PSEP, PCT and qSOFA,respectively. The combination of PSEP, PCT and qSOFA by logisticregression revealed an AUC value of 0.850.

-   -   24 patients were assigned to qSOFA=0, 44 patients to qSOFA=1, 23        patients to qSOFA=2, and 8 patients to qSOFA=3.    -   In 62.5% of the patients with qSOFA=0 the certainty with which a        complicated clinical course (CCC) is ruled-out could be improved        by using additionally the algorithm PSEP <1000 pg/mL and PCT <2        ng/mL (Tab1.1).    -   In patients with qSOFA=1 the algorithm could differentiate        between low risk and high risk of a complicated clinical course        in 34.0% and 65.9%, respectively (Tab1.2).    -   In patients with qSOFA=2 the algorithm could indicate the        majority of 73.9% to rule in a complicated clinical course and        26% to rule out (Tab1.3).    -   In patients with qSOFA=3 the algorithm could indicate 87.5% to        rule in a complicated clinical course and 12.5% to rule out        (Tab1.4).

Summary of ED Study Results:

Rule-out: Rule-in: PSEP < PSEP ≥ 1000 1000 pg/mL and pg/mL and/ Non- NoPCT < or PCT ≥ Survi- survi- CCC CCC 2 ng/mL) 2 ng/mL vors vors All 3366 81 18 n = 99 qSOFA = 0 11 13 15 9 24 0 n = 24 (62.5%) (37.5%) qSOFA =1 29 15 17 27 39 5 n = 44 (34.0%) (65.9%) qSOFA = 2 19 4  6 17 17 7 n =23  (26%) (73.9%) qSOFA = 3 7 1  1 7 2 6 n = 8 (12.5%) (87.5%)

Calculation of the sensitivity, specificity, positive predictive value(PPV) and negative predictive value (NPV) of qSOFA, qSOFA+PCT andqSOFA+PCT+PSEP in predicting hospital mortality and septic shock:

-   -   1. Discrimination of death vs alive by receiver operating        characteristics curve (ROC) analysis

Sensi- Speci- NPV PPV AUC tivity % ficity % % % qSOFA + PCT + PSEP 0.85289.4 7 64.13 96.7 34.0 qSOFA + PSEP 0.848 78.95 73.91 94.4 39.0 qSOFA +PCT 0.824 84.21 72.83 95.7 39.0 qSOFA 0.801 68.42 77.17 92.2 38.2

-   -   2. Discrimination of septic shock vs uncomplicated sepsis by        receiver operating characteristic curve (ROC) analysis

Sensi- Speci- NPV PPV AUC tivity % ficity % % % qSOFA + PCT + PSEP 0.81773.81 76.81 82.8 66.0 qSOFA + PSEP 0.810 78.57 76.81 85.5 67.3 qSOFA +PCT 0.794 54.76 92.75 77.1 82.1 qSOFA 0.765 53.66 84.72 76.2 66.7

-   -   Sensitivity: Probability that a test result will be positive        when the disease is present (true positive rate).    -   Specificity: Probability that a test result will be negative        when the disease is not present (true negative rate).    -   Positive predictive value (PPV): Probability that the disease is        present when the test is positive.    -   Negative predictive value (NPV): Probability that the disease is        not present when the test is negative.

Example 2: Individual Case Studies

Patients with qSOFA=0

Study ID 402

A 71 years old men (size 182 cm, weight 83 Kg, BMI 25) was admitted tothe emergency department with fever and unclear genesis. The measuredtemperature was 39.7° C.

Respiratory rate, RRsyst and the GSC score were 24/min, 101 mmHg and 15,respectively, revealing a qSOFA score of 0.

PSEP and PCT were 693 pg/mL and 1.1 ng/mL indicating rule out ofcomplicated clinical cause according to the algorithm.

The patient was admitted to the general ward and could be dischargedafter 12 days at home without complications.

Study ID 387

A 76 years old women was admitted to the emergency department withpneumonia (size 158 cm, weight 53 Kg, BMI 21.3). Respiratory rate,RRsyst and the GSC score were 26/min, 123 mmHg and 15, respectively,revealing a qSOFA score of 0.

PSEP and PCT were 287 pg/mL and 0.1 ng/mL indicating rule out ofcomplicated clinical cause according to the algorithm.

The patient could be discharged at home from the emergency department.

Patients with qSOFA=1

Study ID 383

A 73 years old men (size 168 cm, weight 88 Kg, BMI=31) was admitted tothe emergency department with pneumonia. Respiratory rate, RRsyst andthe GSC score were 28/min, 125 mmHg and 15, respectively, revealing aqSOFA score of 1.

PESP and PCT were 3744 pg/mL and 0.56 ng/mL indicating moderate risk forprediction of complicated clinical cause and mortality risk according tothe algorithm “qSOFA=1, PSEP >1000 pg/mL or PCT <2 ng/mL” indicates ThePSEP concentration was >1000 pg/mL but the measured PCT value of 0.56ng/mL was below the threshold of 2 ng/mL.

According qSOFA=1 and the very high PSEP value of 3744 pg/mL the patientwas assigned to complicated clinical cause and admitted to the ICU.Instead of mechanical ventilation and dialysis the patient died after 25days during the ICU stay.

Study ID 360

A 84 years old patient (size 162 cm, weight 60 Kg, BMI=22.9) wasadmitted to the emergency department with urinary tract infection.Respiratory rate, RRsyst and the GSC score were 22/min, 112 mmHg and 15,respectively, revealing a qSOFA score of 1.

PSEP and PCT values were 1517 pg/mL and 0.54 ng/mL indicating moderaterisk of complicated clinical cause.

The patient was admitted to the general ward for antibiotic therapy andcould be discharged after 7 days at home.

Study ID 313

A 42 years old men was admitted to the emergency department withpneumonia (size 178 cm, weight 101 Kg, BMI 31.9). Respiratory rate,RRsyst and the GSC score were 22/min, 130 mmHg and 15, respectively,revealing a qSOFA score of 1.

PSEP and PCT were 799 pg/mL and 0.26 ng/mL indicating low risk ofcomplicated clinical cause according to the algorithm.

The patient was admitted to the general ward and received antibiotictherapy for 14 days until he was discharged at home withoutcomplications.

Study ID 458

A 87 years old men was admitted to the emergency department withurosepsis (size 160 cm, weight 70 Kg, BMI 27.3). Respiratory rate,RRsyst and the GSC score were 20/min, 147 mmHg and 11, respectively,revealing a qSOFA score of 1.

PSEP and PCT were 342 pg/mL and 6.4 ng/mL indicating high risk ofcomplicated clinical cause according to the elevated PCT concentration.Also clinically the patient was assigned to severe sepsis underlined bya high CRP concentration of 102 mg/L.

The patient was admitted to the intensive care unit for two days andreceived early goal directed therapy. After further treatment at thegeneral ward for 9 days the patient could be discharged at home withoutcomplications.

Study ID 461

A 68 years old women was admitted to the emergency department withpneumonia (size 174 cm, weight 103 Kg, BMI 34.2). Respiratory rate,RRsyst and the GSC score were 20/min, 110 mmHg and 14, respectively,revealing a qSOFA score of 1.

PSEP and PCT were 236 pg/mL and 8.1 ng/mL indicating high risk ofcomplicated clinical cause according to the elevated PCT concentration.Also clinically the patient was assigned to severe sepsis underlined bya high CRP concentration of 102 mg/L.

The patient was admitted to the intensive care unit for three days andreceived early goal directed therapy. After further treatment at thegeneral ward 7 the patient could be discharged at home withoutcomplication.

Patients with qSOFA=2

Study ID 403

A 87 years old men was admitted to the emergency department withurosepsis (size 175 cm, weight 65 Kg, BMI 21.2). Respiratory rate,RRsyst and the GSC score were 24/min, 74 mmHg and 15, respectively,revealing a qSOFA score of 2.

The algorithm “qSOFA=2, PSEP >1000 pg/mL or PCT >2 ng/mL” indicatesprediction of complicated clinical cause and high mortality risk. Thepatient was admitted to the ICU for early goal directed therapyaccording to PSEP and PCT concentration of 1979 pg/mL and 16 ng/mL,respectively, measured at presentation.

After discharge from the ICU to the general ward the antibiotic therapywas continued but the patient died 5 days later.

Study ID 390

A 64 years female with abdominal pain due to acute cholecystitis wasadmitted to the emergency department (size 163 cm, weight 106 Kg, BMI40). The qSOFA score at presentation was 2 (Respiratory rate, RRsyst andthe GSC score were 28/min, 108 mmHg and 3).

PSEP and PCT values were 1858 pg/mL and 292 ng/mL indicating underlyingsepsis with complicated clinical cause.

The patient was admitted to the ICU for early goal directed therapy andneeded mechanical ventilation. After 5 days on the ICU and 10 days onthe general ward the patient could be discharged at home.

Study ID 357

A 79 years old female (size 160 cm, weight 70 Kg, BMI 27) was admittedto the emergency department with urosepsis. Respiratory rate, RRsyst andthe GSC score were 25 min, 140 mmHg and 13, respectively, revealing aqSOFA score of 2.

PESP and PCT were 1810 ng/L and 2.15 μg/L indicating high risk forprediction of complicated clinical cause and mortality risk according tothe algorithm “qSOFA=1, PSEP >1000 pg/mL, PCT >2 ng/mL”.

The patient received early goal directed therapy and antibiotic therapyfor 18 days at the general ward until discharge at home.

Patients qSOFA=3

Study ID 374

A 87 years old men (size 170 cm, weight 65 Kg, BMI 22.5) suffered fromurinary tract infection and was admitted to the emergency department.Respiratory rate, RRsyst and the GSC score were 24/min, 80 mmHg and 3,respectively, revealing a qSOFA score of 3.

The algorithm “qSOFA=3, PSEP >1000 pg/mL or PCT >2 ng/mL” indicatedprediction of complicated clinical cause and high mortality risk. ThePSEP concentration of 8238 pg/mL was extremely high whereas and the PCTvalue was below 2 ng/mL (0.91 μg/L). Although PCT was <2 ng/mL high riskof worse outcome and mortality risk of >50% could be expected.

The high PSEP concentration of 8238 pg/mL might also be influencedthrough acute kidney disease (AKD) which was indicated by a measuredcreatinine concentration of 1022 μmon. AKD occurs commonly in sepsis andcontributes to mortality risk significantly.

The patient was admitted to the intensive care unit for early goaldirected therapy and died after 5 days.

Study ID 373

A 82 years old men with pneumonia was admitted to the emergencydepartment. Respiratory rate, RRsyst and the GSC score were 24/min, 100mmHg and 7, respectively, revealing a qSOFA score of 3.

The algorithm “qSOFA=3, PSEP >1000 pg/mL or PCT >2 ng/mL” indicatesprediction of complicated clinical cause and high mortality risk. ThePSEP concentration was >1000 pg/mL (1407 ng/L) but the measured PCTvalue of 0.37 ng/mL was below the threshold of 2 ng/mL of the algorithmand below 0.5 ng/mL.

According qSOFA=3 and PSEP >1000 pg/mL the patient was assigned tocomplicated clinical cause and admitted to the ICU. Despite intensivecare with mechanical ventilation and dialysis during the ICU stay thepatient died after 7 days.

Study ID 381

A 78 years old female was admitted to the emergency department urinarytract infection. Respiratory rate, RRsyst and the GSC score were 30/min,91 mmHg and 12 revealing a qSOFA score of 3.

The PSEP concentration of 504 pg/mL was below the threshold of 1000pg/mL whereas the PCT value was 2 pg/ml. According to the algorithmqSOFA=3, PSEP <1000 pg/mL but PCT ≥2 ng/mL complicated clinical causeslike severe sepsis or septic shock could not be excluded. The patientwas admitted to the general ward for antibiotic treatment and wasdischarged after 9 days without complications.

Study ID 389

A 75 years old men was admitted to the emergency department withurosepsis (size 165 cm, weight 100 Kg, BMI 36.7). Respiratory rate,RRsyst and the GSC score were 24/min, 100 mmHg and 11, respectively,revealing a qSOFA score of 3.

The PSEP concentration of 3496 pg/mL was above the threshold of 1000pg/mL and the PCT value was 25.6 ng/mL. According to the algorithmqSOFA=3, PSEP >1000 pg/mL and PCT ≥2 ng/mL complicated clinical causeslike severe sepsis or septic shock could not be excluded.

The patient was admitted to the ICU for 4 days because of need ofdialysis due to acute kidney disease. After discharge to the generalward the patient died after 9 days during hospital stay.

CONCLUSIONS

In patients with qSOFA=0 or qSOFA=1 and a PCT concentration of <2 ng/mLand Presepsin concentration of <1000 pg/mL, a clinical course withoutrisk of complications may be assumed for the patient. If one of the twobiomarkers exceeds the respective limit value, a clinical course withoutrisk of complications cannot be safely eliminated. In a study of 99patients with suspected sepsis in the emergency room, for 24 patientswith qSOFA=0 and for 44 patients with qSOFA=1, a complicated clinicalcourse only could be excluded in 62.5% and 65.9% of cases respectively,although these patients exhibited a “negative” qSOFA (<2)

In patients with qSOFA=2 and a PCT concentration of <2 ng/mL and aPresepsin concentration of <1000 pg/mL, a good prognostic course can beexpected, despite the “positive” qSOFA score. In the above study 26% ofpatients with qSOFA=2 had an uncomplicated clinical course. On the otherhand, patients with a PCT concentration of >2 ng/mL and/or a Presepsinconcentration of >1000 pg/mL are at an increased risk of a complicatedclinical course. Patients like this must be monitored by medical staff,if necessary in the intensive care unit. In the same emergency study in23 patients with qSOFA=2, a complicated clinical course was reliablypredicted in 73% of cases.

In patients with qSOFA=3 and a PCT concentration and Presepsinconcentration of over 2 ng/mL and ≥1000 pg/mL respectively, severebacterial sepsis or septic shock is ensured with high mortality.

Thus, the findings of the present invention show that the combination ofqSOFA with Presepsin and Procalcitonin is more accurate in predicting acomplicated clinical course of sepsis and hospital mortality than theqSOFA score alone. Accordingly, the combined assessment of qSOFA,Presepsin and Procalcitonin according to the proposed algorithm improvesthe risk stratification of patients with suspected sepsis admitted tothe emergency department significantly.

1. A method for aiding in the risk assessment of a patient withsuspected sepsis, comprising (a) determining the amount of the biomarkerPresepsin in a sample from a patient with suspected sepsis who has aknown qSOFA (quick Sequential Organ Failure-Assessment) score of 0, 1, 2or 3, (b) determining the amount of the biomarker Procalcitonin (PCT) ina sample from the patient, (c) comparing the amounts determined in steps(b) and (c) to reference amounts, and (d) aiding in the risk assessmentof a patient with suspected sepsis.
 2. The method of claim 1, whereinthe patient is a human patient.
 3. The method of claim 1, wherein thesample is a blood, serum or plasma sample.
 4. The method of claim 1,wherein the patient is a patient who presents with suspected sepsis. 5.The method of claim 1, wherein the risk of mortality, such asin-hospital mortality, a complicated clinical course, severe sepsisand/or septic shock is assessed.
 6. The method of claim 5, wherein thecomplicated clinical course is defined as the need for organ supportmeasures required during intensive care unit (ICU) stay, such asadministration of intravenous fluids, vasopressors, mechanicalventilation or renal replacement therapy.
 7. The method of claim 1,wherein the subject has a known qSOFA (quick Sequential OrganFailure-Assessment) score of 0 or
 1. 8. The method of claim 7, whereinan amount of Presepsin in the sample from the subject which is largerthan the reference amount for Presepsin and/or an amount of PCT in thesample from the subject which is larger than the reference amount forPCT is indicative for a subject who is at risk.
 9. The method of claim7, wherein an amount of Presepsin in the sample from the subject whichis lower than the reference amount for Presepsin and an amount of PCT inthe sample from the subject which is lower than the reference amount forPCT is indicative for a subject who is not at risk.
 10. The method ofclaim 1, wherein the subject has a known qSOFA (quick Sequential OrganFailure-Assessment) score of 2 or
 3. 11. The method of claim 10, whereinan amount of Presepsin in the sample from the subject which is largerthan the reference amount for Presepsin and/or an amount of PCT in thesample from the subject which is larger than the reference amount forPCT is indicative for a subject who is at risk.
 12. The method of claim10, wherein an amount of Presepsin in the sample from the subject whichis lower than the reference amount for Presepsin and an amount of PCT inthe sample from the subject which is lower than the reference amount forPCT is indicative for a subject who is not at risk.
 13. The method ofclaim 1, further comprising recommending or initiating a suitabletherapeutic measure.
 14. The method of claim 13, wherein the therapeuticmeasure is selected from recommended guidelines for management ofsepsis, if the subject has been assessed to be at risk.
 15. The methodof claim 13, wherein the therapeutic measure may be treatment ofinfection or further investigation or other aspects of care deemednecessary by a practitioner, if the subject has been assessed to be notat risk.
 16. The method of claim 1, wherein the reference amount forPresepsin is within a range from about 500 pg/mL to about 1500 pg/mL orabout 750 pg/mL to about 1250 pg/mL, and/or wherein the reference amountfor PCT is within a range from about 1.5 ng/mL to about 2.5 ng/mL.
 17. Amethod for aiding in the risk assessment of a patient with suspectedsepsis, comprising (a) obtaining the patient's qSOFA (quick SequentialOrgan Failure-Assessment) score, (b) determining the amount of thebiomarker Presepsin in a sample from the patient with suspected sepsis,(c) determining the amount of the biomarker Procalcitonin (PCT) in asample from the patient, (d) comparing the amounts determined in steps(b) and (c) to reference amounts, and (e) aiding in the risk assessmentof the patient.
 18. The method of claim 17, wherein the patient's qSOFAscore is based on the patient's respiratory rate (>22/min), thepatient's systolic blood pressure (<100 mmHg), and the presence orabsence of an altered mentation (GCS <15).
 19. A computer-implementedmethod for the assessment of a patient with suspected sepsis, comprising(a) receiving at a processing unit (a1) a value for the amount of thebiomarker Presepsin in a sample from a patient with suspected sepsis whohas a known qSOFA (quick Sequential Organ Failure-Assessment) score of0, 1, 2 or 3 and (a2) a value for the amount of the biomarkerProcalcitonin in a sample from the patient, (b) processing the valuesreceived in step (a) with the processing unit, wherein said processingcomprises (b1) retrieving from a memory one or more threshold values forthe amount of the biomarker Presepsin, and one or more threshold valuesfor the amount of the biomarker Procalcitonin, (b2) comparing the valuesreceived in step (a) with the respective threshold values retrieved instep (b1), and (c) providing an assessment of the patient via an outputdevice, wherein said assessment is based on the results of step b). 20.A computer-implemented method for the assessment of a patient withsuspected sepsis, comprising (a) receiving at a processing unit (a1) avalue for the patient's qSOFA (quick Sequential OrganFailure-Assessment) score, (a2) a value for the amount of the biomarkerPresepsin in a sample from the patient, and (a3) a value for the amountof the biomarker Procalcitonin in a sample from the patient, (b)processing the values received in step (a) with the processing unit,wherein said processing comprises (b1) retrieving from a memory athreshold value for the qSOFA score, one or more threshold values forthe amount of the biomarker Presepsin, and one or more threshold valuesfor the amount of the biomarker Procalcitonin, (b2) comparing the valuesreceived in step (a) with the respective threshold values retrieved instep (b1), and (c) providing an assessment of the patient via an outputdevice, wherein said assessment is based on the results of step b). 21.The method of claim 19, wherein the output device is a display,configured for presenting the assessment.
 22. The method of claim 21,wherein the value for the amount of the biomarker Presepsin and/orProcalcitonin is the value for the amount of the biomarker in a blood,serum or plasma sample.